THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT =
YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
This
Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out
treatment, payment or health care operations and for other purposes that are
permitted or required by law. It
also describes your rights to access and control your protected health
information. “Protected
health information” is information about you, including demographic
information, that may identify you and that relates to your past, present or
future physical or mental health or condition and related health care servi=
ces.
We
are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our not=
ice,
at any time. The new notice w=
ill be
effective for all protected health information that we maintain at that
time. Upon your request, we w=
ill
provide you with any revised Notice of Privacy Practices. You may request a revised version =
by
accessing our website, or calling the office and requesting that a revised =
copy
be sent to you in the mail or asking for one at the time of your next
appointment.
1. =
Uses
and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff a= nd others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information = may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.
Following
are examples of the types of uses and disclosures of your protected health =
information
that your physician’s office is permitted to make. These examples are=
not
meant to be exhaustive, but to describe the types of uses and disclosures t=
hat
may be made by our office.
Treat=
ment: We will use and disclose your prot=
ected
health information to provide, coordinate, or manage your health care and a=
ny
related services. This includ=
es the
coordination or management of your health care with another provider. For
example, we would disclose your protected health information, as necessary,=
to
a home health agency that provides care to you. We will also disclose protected he=
alth
information to other physicians who may be treating you. For example, your
protected health information may be provided to a physician to whom you have
been referred to ensure that the physician has the necessary information to
diagnose or treat you. In add=
ition,
we may disclose your protected health information from time-to-time to anot=
her
physician or health care provider (=
e.g.,
a specialist or laboratory) who, at the request of your physician, becomes
involved in your care by providing assistance with your health care diagnos=
is
or treatment to your physician.
Payme=
nt: Your protected health
information will be used and disclosed, as needed, to obtain payment for yo=
ur
health care services provided by us or by another provider. This may include certain activitie=
s that
your health insurance plan may undertake before it approves or pays for the
health care services we recommend for you such as: making a determination of
eligibility or coverage for insurance benefits, reviewing services provided=
to
you for medical necessity, and undertaking utilization review activities.
Healt=
h Care
Operations: We may use or disclo=
se, as
needed, your protected health information in order to support the business
activities of your physician’s practice. These activities include, but are =
not
limited to, quality assessment activities, employee review activities, trai=
ning
of medical students, licensing, fundraising activities, and conducting or
arranging for other business activities.
We will share your protected health information =
with
third party “business associates” that perform various activiti=
es
(for example, billing or transcription services) for our practice. Whenever an arrangement between our
office and a business associate involves the use or disclosure of your
protected health information, we <=
/b>will
have a written contract that contains terms that will protect the privacy of
your protected health information.=
We may use or disclose your protected health
information, as necessary, to provide you with information about treatment
alternatives or other health-related benefits and services that may be of
interest to you. You may cont=
act
our Privacy Officer to request that these materials not be sent to you.
We may use or disclose your demographic informat=
ion
and the dates that you received treatment from your physician, as necessary=
, in
order to contact you for fundraising activities supported by our office.
Other
Permitted and Required Uses and Disclosures That May Be Made Without Your
Authorization or
We may use or disclose your protected health
information in the following situations without your authorization or provi=
ding
you the opportunity to agree or object.&nb=
sp;
These situations include:
Uses and
Disclosures of Protected Health Information Based upon Your Written
Authorization
Other uses and disclosures of your protected hea=
lth
information will be made only with your written authorization, unless other=
wise
permitted or required by law as described below. You may revoke this authorization =
in
writing at any time. If you r=
evoke
your authorization, we will no longer use or disclose your protected health
information for the reasons covered by your written authorization. Please understand that we are unab=
le to
take back any disclosures already made with your authorization.
Other
Permitted and Required Uses and Disclosures That Require Providing You the =
We may use and disclose your protected health
information in the following instances.&nb=
sp;
You have the opportunity to agree or object to the use or disclosure=
of
all or part of your protected health information. If you are not present or able to =
agree
or object to the use or disclosure of the protected health information, then
your physician may, using professional judgement, determine whether the
disclosure is in your best interest.
2. =
Your
Rights
Following is a stateme= nt of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You h=
ave
the right to inspect and copy your protected health information.=
This means you may inspect and obt=
ain a
copy of protected health information about you for so long as we maintain t=
he
protected health information. You
may obtain your medical record that contains medical and billing records and
any other records that your physician and the practice uses for making
decisions about you. As permi=
tted
by federal or state law, we may charge you a reasonable copy fee for a copy=
of
your records.
Under federal law, however, you may not inspect =
or
copy the following records: psychotherapy notes; information compiled in
reasonable anticipation of, or use in, a civil, criminal, or administrative
action or proceeding; and laboratory results that are subject to law that
prohibits access to protected health information. Depending on the
circumstances, a decision to deny access may be reviewable. In some circumstances, you may hav=
e a
right to have this decision reviewed.
Please contact our Privacy Officer if you have questions about acces=
s to
your medical record.
You h=
ave
the right to request a restriction of your protected health information. This means you may ask us not to u=
se or
disclose any part of your protected health information for the purposes of
treatment, payment or health care operations. You may also request that any part=
of
your protected health information not be disclosed to family members or fri=
ends
who may be involved in your care or for notification purposes as described =
in
this Notice of Privacy Practices.
Your request must state the specific restriction requested and to wh=
om
you want the restriction to apply. <=
/span>
Your physician is not required to agree to a
restriction that you may request.
If your physician does agree to the requested restriction, we may not
use or disclose your protected health information in violation of that
restriction unless it is needed to provide emergency treatment. With this in mind, please discuss =
any
restriction you wish to request with your physician. You may request a restriction by completing the form for Authorization for the use and/or d=
isclosure
of Protected Health Information.
You h=
ave
the right to request to receive confidential communications from us by
alternative means or at an alternative location. We will accommodate
reasonable requests. We may also condition this accommodation by asking you=
for
information as to how payment will be handled or specification of an
alternative address or other method of contact. We will not request an explanation=
from
you as to the basis for the request. Please make this request in writing to=
our
Privacy Officer.
You m=
ay
have the right to have your physician amend your protected health informati=
on. This means you may request an
amendment of protected health information about you in a designated record =
set
for so long as we maintain this information. In certain cases, we may deny your
request for an amendment. If =
we
deny your request for amendment, you have the right to file a statement of
disagreement with us and we may prepare a rebuttal to your statement and wi=
ll
provide you with a copy of any such rebuttal. Please contact our Privacy Officer=
if
you have questions about amending your medical record.
You h=
ave
the right to receive an accounting of certain disclosures we have made, if =
any,
of your protected health information. =
This
right applies to disclosures for purposes other than treatment, payment or
health care operations as described in this Notice of Privacy Practices.
You h=
ave
the right to obtain a paper copy of this notice from us, upon request, even i=
f you
have agreed to accept this notice electronically.
3. =
Complaints
You
may complain to us or to the Secretary of Health and Human Services if you
believe your privacy rights have been violated by us. You may file a complaint with us by
notifying our Privacy Officer of your complaint. We will not retaliate against you =
for
filing a complaint.
You may contact our Privacy Officer,
This notice was published and becomes effective =
on
September 01, 2005.
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4=
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© 2003 American Medical Association
All Rights Reserved